Introduction to Insurance Billing Terminology
audit
to check the accuracy of financial accounts and records
Explanation of Benefits (EOB)
document sent by the insurance company to the provider and the patient explaining the allowed charge amount, the amount reimbursed for services, and the patient's financial responsibilities.
EOB
explanation of benefits
Copayment
a fixed fee paid by the patient at the time of an office visit
Deductible
a specified amount of money that the insured must pay before an insurance company will pay a claim
indigent
(adj.) needy, impoverished
beneficiary
A designated person who receives funds from an insurance policy.
claim
A formal request for payment from an insurance company for service provided.
fee schedule
A list of the fixed fees for services is a
capitation
A payment arrangement for healthcare providers in which the provider is paid a set amount whether the patient received services or not.
Co-insurance
A percentage of the bill that patient must pay after meeting the deductible.
Precertification
A process required by some insurance carriers in which the provider must prove medical necessity before performing a procedure.
RBRVS
A system used to determine how much providers should be paid for service rendered.
policy
A written agreement between two parties, in which one party agrees to pay another party if certain specified circumstances occur.
provider network
An approved list of physicians, hospitals and other providers
health insurance exchange
An online marketplace where you can compare and buy individual health insurance plans.
online insurance web portal
An online service which allows providers to look up patient's insurance information.
referral
An order from a primary care provider for the patient to see a specialist or obtain services.
Claims Clearinghouse
An organization that accepts claims from the provider and reformats the data and submits the claim.
eligibility
Meeting the requirements to participate in the healthcare plan.
medical necessity
Services or supplies that are used to treat the patient's diagnosis meet the accepted standard of medical practice.
Medically necessary
Services that are needed to improve the patient's current health are considered
NPI
The identifier assigned to healthcare providers by license and medical specialties.
gatekeeper
The primary care provider who is in charge of a patient's treatment
adjudicate
To settle or determine with a court of law.